Pregnancy: CNS complications

Adrian Marchidann MD (Dr. Marchidann of SUNY Health Science Center has no relevant financial relationships to disclose.)
James G Greene MD PhD, editor. (Dr. Greene of Emory University School of Medicine has no relevant financial relationships to disclose.)
Originally released February 2, 2000; last updated June 2, 2017; expires June 2, 2020

This article includes discussion of pregnancy: CNS complications, Wernicke encephalopathy, ischemic stroke, hemorrhagic stroke (intracerebral hemorrhage), subarachnoid hemorrhage, preeclampsia (toxemia of pregnancy), and eclampsia. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Given the acuity of possible outcomes, as well as the added clinical dimension of an unborn child, the pregnant patient can prove to be a challenge for the treating neurologist. As well, the postpartum period carries with it significant and unique neurologic risks. In this article, the author reviews the common central neurologic complications seen in pregnancy and the postpartum period. The key presenting features of eclampsia are discussed as well as ischemic and hemorrhagic cerebrovascular events.

Key points

 

• Pregnancy and delivery are associated with a multitude of physiologic changes that may trigger complications specific to pregnancy or influence the course of multiple neurologic and systemic disorders.

 

• Intractable vomiting may lead to Wernicke encephalopathy, a potentially fatal condition that requires a high index of suspicion and urgent administration of thiamine intravenously.

 

• Most untreated or insufficiently treated patients who survive the acute Wernicke encephalopathy develop Korsakoff syndrome, characterized by anterograde and retrograde amnesia.

 

• The risk of ischemic and hemorrhagic stroke is increased mostly in the peripartum and postpartum periods.

 

• The risk factors of stroke in young pregnant women may differ from those found in the older population and are related in particular to venous thrombosis, reversible cerebral vasoconstriction and preeclampsia/eclampsia. Looking for causes of stroke in the young is equally important.

 

• Low dose aspirin may cause gastroschisis during the first trimester, but may be given safely thereafter for prevention of most types of stroke.

 

• Preeclampsia may be prevented with careful blood pressure control and a small dose of aspirin; eclampsia should be treated with intravenous magnesium sulfate.

 

• Heparin is the preferred treatment in patients with thrombophilia and cardioembolism, except in those with an older mechanical mitral valve and history of thromboembolism who may benefit from warfarin.

 

• Subarachnoid hemorrhage should be treated according to the guidelines for nonpregnant women.

Historical note and terminology

The physiologic changes that occur during pregnancy and the puerperium can adversely affect the central nervous system and complicate the management of preexisting neurologic conditions. The effect of pregnancy on chronic neurologic conditions such as epilepsy, multiple sclerosis, myasthenia gravis, and migraine will not be discussed here.

Additionally, pregnancy is associated with complications of anesthesia during and after delivery, which may be difficult to distinguish from those of pregnancy. Headache following dural puncture and leak is the most frequent CNS complication of anesthesia. Spinal cord lesions due to trauma, compression, ischemia, or total spinal block occur rarely, but the high morbidity and mortality associated with them demand a low threshold for suspicion and rapid intervention. Seizures during anesthesia may also be triggered by selective inhibition of the inhibitory neurons.

Diagnosis and management of the central nervous system disorders that can develop during pregnancy will be specifically addressed. Eclampsia is reviewed in this article, and it is also covered as an individual article.

Wernicke encephalopathy, a potentially fatal and yet treatable complication of thiamine deficiency, was described initially by Carl Wernicke in 1881 in 2 alcoholic patients. Its association with hyperemesis gravidarum was later noted (Verhaart et al 1955). In 1888 Sir William Gowers described severe convulsions in women with hypertension, proteinuria, and edema. This clinical syndrome, known as eclampsia or toxemia of pregnancy, is a unique disease associated with pregnancy-induced hypertension. Cerebrovascular events were also prominent causes of maternal morbidity and mortality. In 1899 Edward Lazard described the first intracerebral hemorrhage in pregnancy, noted at autopsy to be the result of a ruptured aneurysm. John Abercrombie made the first autopsy description of puerperal cerebral phlebothrombosis in 1828; however, the clinical syndrome of central venous thrombosis was not described until Gowers in 1893.

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